Download - Developing web-based Triple P ‘Positive Parenting Programme’ for families of children with asthma
Developing web-based Triple P ‘Positive ParentingProgramme’ for families of children with asthma
S.-A. Clarke,* R. Calam,* A. Morawska† and M. Sanders†
*Division of Clinical Psychology, University of Manchester, Manchester, UK and†Parenting and Family Support Centre, School of Psychology, The University of Queensland, Brisbane, Qld, Australia
Accepted for publication 17 March 2013
Keywordschildhood asthma,engagement, parentinginterventions, Triple P
Correspondence:Sally-Ann Clarke, PhD,MSc, AFBPsS, HealthPsychologist and TraineeClinical Psychologist,Division of ClinicalPsychology, 2nd Floor,Zochonis Building,University of Manchester,Brunswick Street,Manchester M13 9PL, UKE-mail: [email protected]
AbstractBackground We examined the feasibility of self-directed Triple P ‘Positive Parenting Programme’
for optimizing parents’ management of childhood asthma and behaviour.
Methods Eligible families were invited to access asthma-specific web-based Triple P as part of a
preliminary randomized controlled study.
Results Initial study information and introductory website pages received considerable interest
but intervention uptake was poor with high rates of attrition.
Conclusions Although parents of children with asthma show willingness to access web-based
parenting support, further work is necessary to develop engaging websites and determine barriers
to uptake, and adherence to online parenting interventions with this population.
Introduction
Approximately one in every 11 UK children is affected by child-
hood asthma, a chronic inflammatory disorder of the airways
(Asthma UK 2004). Ineffective asthma management leads to
poor symptom control (McQuaid et al. 2007) and risk of hos-
pital admission (Ordonez et al. 1998) with serious implications
for child health-related quality of life (HRQOL) in physical,
emotional, social and school functioning domains (Bender
1995; Graetz & Shute 1995).
Parenting and child behaviour can impact upon symptom
control and adversely affect health outcomes. Parents, critical to
successful asthma management, frequently report difficulties
with the tasks involved (Gibson et al. 1995; Milgrom et al.
1996), while children with asthma display greater behavioural
difficulties compared with healthy peers (Calam et al. 2003,
2005). Asthma-specific difficulties, such as tantrums in response
to treatment, create additional challenges for parenting and
impair treatment adherence (Morawska et al. 2008).
A review of psychosocial interventions designed to improve
HRQOL among asthmatic children (Clarke & Calam 2011)
identified four of 18 studies reporting significant improve-
ments. Asthma education programmes (72%) dominated
research, yet there is limited evidence that simply educating
families about asthma is sufficient to significantly improve
broad psychosocial outcomes such as HRQOL. One explanation
is that education does not address parents’ ability to put knowl-
edge into practice. Put simply, asthma education tells parents
what to do in order to manage childhood asthma, not how to
do it.
Triple P (Positive Parenting Programme) is a multi-level,
evidence-based, parenting intervention grounded in social
learning theory that aims to increase parents’ self-efficacy
in raising their children. Triple P has prevented behavioural
and emotional problems in many contexts (Sanders 1999).
In preliminary studies of parents of chronically ill children
(F. Doherty, submitted; A. Morawska, in prep.) it has helped
parents develop skills and confidence in managing illness and
bs_bs_banner Child: care, health and developmentOriginal Article doi:10.1111/cch.12073
© 2013 John Wiley & Sons Ltd492
behaviour. Online formats offer cost-effective methods for pro-
viding easily accessible and widely available, intensive parenting
support for hard to reach groups, such as families of chronically
ill children. In line with the ‘Every Family’ initiative to improve
access and delivery of preventive parenting interventions
(Sanders et al. 2005), the present study aimed to evaluate the
feasibility of self-directed, web-based (level 4) Triple P with
families of children with asthma in the UK.
Method
Design
A randomized controlled study employing a mixed within-
between-subjects design comparing 8 weeks of web-based
Triple P with a wait-list control group.
Participants
University of Manchester ethics approval was obtained. Eligible
families were parents of children with asthma aged 2–8 years
who could read English. Web-based Triple P has been validated
with this age. Children with significant physical or learning
disabilities were excluded. In order to increase intervention
reach we adopted a broad and wide-reaching recruitment strat-
egy over a 7-month period (June 2010–December 2010) in the
UK. Flyers and emails including brief information about the
study, eligibility criteria and an invitation to participate were
circulated to employees of private companies and public serv-
ices, and through providers of child services and media outlets.
The study website was available to parents over a 20-month
period (June 2010–February 2012).
Intervention
An online self-directed intervention including two components:
1 Asthma-specific tip sheets (n = 2) (Morawska 2008, 2009)
available for the study duration providing brief education
about asthma management and links between asthma, behav-
iour and parenting.
2 Group seminar series Triple P (Sanders 1999; Zubrick
et al. 2005) including weekly video-clips (approximately
10 min) to enhance parental knowledge, skills, confidence,
self-sufficiency and resourcefulness; promote more nurtur-
ing, safe, engaging, non-violent and low conflict environ-
ments for children; and promote children’s social, emotional,
language, intellectual and behavioural competencies through
positive parenting practices.
Procedure
Parents were invited to access the study online via the study
website address and completed stages outlined in Table 1. All
parents were recruited through the same procedure and were
randomly assigned to the intervention or control group after
completing baseline measures.
Measures
Measures (Table 2) took parents approximately 30 min to com-
plete. Children did not complete questionnaires. Where possi-
ble, one-sample t-tests were used to compare baseline scores
with a sample of parents of asthmatic children enrolled in a
similar Triple P study (A. Morawska, in prep.).
Table 1. Stages of participation
Stage 1 Read electronic information sheet with opportunities to ask questions via the researcher’s email address or telephone number.Stage 2 Complete a brief screen to check eligibility criteria was met. Families not eligible did not proceed to stage 3 and were provided with the
researcher’s contact details for any questions.Stage 3 Provide online informed consent.Stage 4 All parents asked to complete baseline measures.Stage 5 Electronic randomization followed by access to the online intervention (intervention group), or a request to wait 8 weeks before
starting the intervention (control group). To test for differential expectancies associated with being randomly assigned to the twotreatments, parents were asked pre and immediately post-randomization to rate ‘how confident are you that your child will benefit fromthe intervention they will receive’ on a Likert-type scale (1–10).
Stage 6 Intervention group asked to complete weekly asthma diary cards and online intervention (prompted by email reminders).Stage 7 All parents asked to complete post-treatment measures online (prompted by email reminders).Stage 8 Control group allowed access to online intervention and sent the Triple P workbook by post.Stage 9 All parents asked to complete follow-up questionnaires online 8 weeks post-baseline assessment (prompted by email reminders).
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© 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 4, 492–497
Results
Website usage
Log analyser software (http://www.deep-software.com/) was
used to obtain descriptive statistics for website usage between 13
May 2010 and 12 January 2012. Estimates suggest that the home
page was viewed 668 times, the information sheet 195 times and
the consent form 140 times.1
Intervention uptake
Of the 140 views of the consent form, 14 eligible parents
provided consent and registered for the online study. Thirteen
completed baseline questionnaires (intervention group n = 8)
(Tables 3 and 4). No significant differences in baseline scores
were found when compared with the Morawska 2012 sample.
Adherence and attrition
No family completed the intervention and all had discontinued
the study by week four. Families dropped out at week one
(n = 12) and week four (n = 1). One family completed post-
intervention measures.
In the control group (n = 5), all families discontinued the
study after baseline questionnaires with no family logging on
to access the intervention 8 weeks later, despite two email
reminders to inform them that they could start.
All families were contacted by email and invited to give feed-
back about reasons for discontinuing the study and potential
areas for improvement to the website and intervention. One
family responded. Reasons included not having time, no per-
ceived need to change parenting practices, and only moderate
interest in the intervention prior to registering.
Discussion
Statistics for website usage suggest sufficient interest in the
study to warrant further research into online interventions for
this population. Parents initially responded favourably to the
study, by viewing the home page for further information. This
is consistent with suggestions that parents want online inter-
ventions (Sanders & Turner 2002; Sanders et al. 2011) and use
the internet for asthma information (Oermann et al. 2003),
and suggests parents may be interested in obtaining asthma
management and parenting support via the internet.
However, intervention uptake was low with very few parents
(approximately 10% of those who viewed the consent form)
providing consent and registering for the study. Furthermore,
attrition was high with no family adhering to the intervention.
This is perhaps surprising given previous research documenting
prevalent child behavioural and asthma management difficul-
ties within this population (Calam et al. 2003, 2005) and clearly
indicates further work is needed to explore engagement within
this population.
1 It is not possible to provide exact statistics regarding website usage as visits
from web-crawlers were also frequent. Estimates exclude visits from the Univer-
sity of Manchester IP address range (most likely to be members of the research
team) and visits, which were clearly from search engine crawlers. Because of
limitations with the ways in which data are logged it is not possible to detect how
many views were repeat visits from the same person (i.e. a parents who might
have viewed the site several times while deciding to take part would have been
logged as a new ‘view’ each time).
Table 2. Measures
Demographicinformation
Family Background Questionnaire (FBQ); routinely used in Triple P outcome research for demographic information(socio-economic status, ethnic background, marital status, parent and child age and gender and health).
Medical information Information regarding the child’s asthma history (treatment, exacerbation rate, courses of prednisolone, hospital admissions,and accident and emergency attendances).
Weekly asthma diarycard
Information about the child’s symptoms in the previous week.
HRQOL The Juniper Paediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQOL) (Juniper et al. 1996a,b); assessing the impactof asthma, including limitations on daily activity and stress on the parent. There are 13 questions in two domains (activitylimitations and emotional function) selected on the basis of their importance to parents themselves. Items are rated on aseven-point Likert scale. Higher scores indicate positive quality of life (activity limitations maximum score = 28, emotionalfunction maximum score = 63).
Child behaviour Eyberg Child Behavior Inventory (ECBI) (Eyberg & Pincus 1999); a 36-item measure of parental perceptions of disruptive behaviourin children between the ages of 2 and 16. Higher ‘intensity’ scores indicate that the problem occurs with greater frequency.Higher ‘problem’ scores indicate lower parental tolerance for child behaviour problems. Clinical cut-off scores are 127 for theIntensity score and 11 for the Problem score (Eyberg & Ross 1978).
Asthma parentingbehaviours
Asthma Behaviour Checklist (ABC) (Morawska et al. 2008); a 22-item measure of parental efficacy for managing asthma behaviour.Parents rate the extent to which the behaviour has been a problem for them on a seven-point Likert scale, and how confidentthey are that they can successfully deal with the behaviour on a 10-point liker scale.
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© 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 4, 492–497
Despite accessing the home page, most parents did not
register. Consequently information on introductory pages
requires careful consideration in order to attract parents. Our
informed consent process was perhaps too lengthy or complex
for a remote online format. Furthermore, parents may have
responded negatively to requests in our consent form: (1) for
permission to contact the child’s general practitioner (GP)
about study participation; and (2) for parents to contact the GP
should concerns about child behaviour or asthma arise during
the course of the study. This could be addressed by providing
further information about how online data are used, stored and
protected, and offering more formal support for parents in the
form of a helpline or follow-up calls.
In addition to generic Triple P video-clips we provided
written information about asthma and Triple P, and ways in
which Triple P might help parents develop confidence in asthma
management. Feedback from parents who accessed the website
but did not register for the study would have helped identify
Table 3. Baseline measures: family demographic and child asthma information (n = 13)
Family demographic information (n = 13)
Child mean age = 3.65 years (1.70 SD, range 2–7 years)Child gender Parent relationship to child
Male n = 8 Mother n = 13Female n = 5 Father n = 0
Child ethnic group Parent marital statusWhite n = 10 Married n = 7Mixed n = 2 Separated n = 2Pakistani n = 1 Live in partner n = 3
Never married/no partner n = 1
Child asthma information (n = 13)
Severity of symptoms Severity of attacksOccur less than once a week n = 6 Mild (breathless when walking, able to talk in sentences, moderate wheeze) n = 8Occur more than once a week but less than once a day n = 3 Moderate (breathless when talking, talks in phrases, loud wheeze) n = 1Occur daily but night-time symptoms less than once a week n = 1 severe (breathless even when resting, talks in words, loud wheeze) n = 4Occur daily and night-time symptoms are frequent n = 3
Preventer medication prescribed Child ever hospitalized because of asthmaYes n = 11 Yes n = 5No n = 2 No n = 8
Reliever medication prescribed Child ever visited accident and emergency because of asthmaYes n = 11 Yes n = 5No n = 2 No n = 8
Prednisolone prescribed in last 12 monthsYes n = 4No n = 9
Table 4. Means and SD for baseline measures (n = 13) and comparison with A. Morawska (in prep.)
Measures
n = 13 study sample n = 41 asthma sample (A. Morawska, in prep.)
Mean (SD) Range Mean (SD) Range
HRQOL score Not assessed Not assessedPACQOL activity 20.03 (2.64) 15.75–22.75PACQOL emotional 47.70 (6.84) 36.56–56.78
Child behaviour scoreECBI intensity 124.25 (34.29) 69–187 128.17 (33.08) 62–186ECBI problem 13.92 (9.32)* 0–29 15.34 (7.13)* 4–36
Asthma parenting behavioursABC extent 43.30 (11.05) 34–68 43.39 (19.13) 22–91ABC confidence 183.10 (26.26) 139–220 186.97 (36.74) 40–220
*Within clinical range �11.HRQOL, health-related quality of life; PACQOL, Paediatric Asthma Caregiver Quality of Life Questionnaire; ECBI, Eyberg Child Behavior Inventory; ABC, AsthmaBehaviour Checklist.
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the acceptability of this message but could not be obtained.
It is possible that parents did not perceive their child’s behav-
iour to be problematic [mean Eyberg Child Behavior Inventory
(ECBI) intensity score was within the normal range although
approaching clinical cut-off], or did not identify an explicit link
between generic parenting practices and asthma-management
behaviour.
The format and content of interventions with this popu-
lation require further pilot work before future attempts at a
full-scale web-based trial. Parents who viewed our inter-
vention mostly disengaged after video-clips at session one,
which introduced parents to generic Triple P principles such
as praise and limit-setting. Additional asthma-specific visual
materials at each session could help promote engagement and
retention to the intervention. This might include video-clips
that complement written asthma-specific tip sheets and dem-
onstrate parents using Triple P strategies with asthma-specific
issues.
Our sample did not differ on baseline measures when
compared with A. Morawska (in prep.), and did not report
substantial difficulties with asthma symptoms, HRQOL,
parental efficacy for managing asthma behaviour, or frequency
(intensity) of child behaviour problems, and so may not
have included those with the greatest difficulties. Interestingly,
the mean ECBI ‘problem’ score (the extent to which beha-
viour is perceived as problematic) was within the clinical
range while the mean ECBI ‘intensity’ score (frequency of
the behaviour) was within the normal range, although
approaching clinical cut-off. This highlights the importance
of parental perceptions of the impact of child behaviour on
the family and resources to manage the behaviour, beyond
simply intensity or frequency with which behaviour occurs.
Parents’ own mental well-being and attributions for child
behaviour, and the wider family context, are therefore likely
to influence engagement and non-completion with parenting
interventions, and could be measured and targeted in future
interventions.
Emotional difficulties, such as parent and child anxiety
about asthma, might also be addressed, while wider contextual
issues related to asthma outcomes, such as smoking in the
family household, could be additional areas for intervention,
or formal assessment at least. Parents might also benefit from
an additional online support forum through which they could
discuss and troubleshoot idiosyncratic issues and obtain peer
feedback.
Feedback from recruitment to similar studies of Triple P
for diabetes (F. Doherty, submitted), and asthma or eczema
(A. Morawska, in prep.), suggests engagement difficulties
are specific to asthma, and that the nature of childhood illness
may lead to different uptake. It is striking that online Triple P
for diabetes (F. Doherty, submitted) encountered no difficulty
with recruitment despite using the same website designer as
our study. One possibility is the intermittent nature of asthma
attacks such that parents are less likely to perceive problems
unless there is a crisis. Conditions with more enduring symp-
toms, and requiring more demanding daily management
routines, such as eczema and diabetes, may create different
challenges for parents and greater awareness that their child’s
behaviour could be a factor in their illness and management.
Other illness-specific factors may include parents’ perceptions
of the seriousness of the condition, threat to health if the child
is non-compliant with treatment, and links between managing
behaviour and managing illness-related activities and health-
care administration. Further work to clarify ways in which to
present links between parenting practices and specific health
conditions are therefore necessary.
Intervention-related factors, including website design,
intervention length and self-directed format may partly
account for attrition. The challenge for researchers is to
facilitate uptake and commitment to online interventions
without face-to-face contact with families. In this study few
parents contacted the researcher for further information, thus
opportunities to allay concerns were limited. Access to testi-
monials from parents with experience of Triple P may be one
strategy for helping parents make informed choices about the
relevance and potential benefits of interventions (Morawska
et al. 2011).
Parenting interventions tailored to the needs of chronically
ill children are not routinely available in the National Health
Service. At a local level clinicians can adapt existing pro-
grammes to meet service users’ needs but few empirical
studies exist. This is a new area of research activity and feasi-
bility studies offer valuable information for clinicians and
researchers planning future interventions. Our data raise
important questions about differences in engagement with
parenting interventions between populations of chronically
ill children. Findings indicate a need for further work with
parents of children with asthma to explore barriers to uptake
of parenting interventions and factors relating to adherence
and attrition, before attempting an outcome study. Future
questions relate to: (1) uptake; ‘what factors affect whether
parents respond to online interventions?’; (2) adherence; ‘what
factors promote intervention completion?’; (3) attrition;
‘where do parents drop out and why?’; and (4) outcome; ‘what
percentage of families who adhere show improvements in
outcomes such as HRQOL and asthma management?’
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© 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 4, 492–497
Key messages
• Parents of children with asthma showed sufficient initial
interest in the online Triple P to warrant further research
into web-based parenting support for this population.
• Despite initial interest, intervention uptake was low and
attrition was high, when compared with other research
with chronically ill populations.
• Engagement with parenting interventions is influenced by
illness-specific factors.
Conflict of interests
We can confirm that there are no conflicts of interests.
Acknowledgements
We wish to acknowledge Austin Lockwood, the website designer
and technician providing technical support for this online
study.
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